Management of eosinophilic esophagitis in adults
Question:
2/16/2018
Patient diagnosed with EOE with minimal symptoms only. Patient's symptoms relieved after esophagus was stretched 10 years ago without any other GI symptoms. But only in the past year, his symptoms of dysphagia, choking on food recurred. Esophagus stretched again but now diagnosed with EOE. Does he need to be treated for EOE if has no symptoms. What is the long term consequence if left untreated? If treated there is no symptoms to guide if treatment is effective or not, other than many years down the road, will have dysphagia again if history will repeat the way he had in the past 10 years.
Answer:
There are no definitive answers to your questions as EoE is heterogeneous. The adult experience differs from that in childhood in many respects. Some adults have primarily a fibrotic histology with less inflammation and these individuals are likely to do well with periodic dilation. Another group is primarily inflammatory without fibrosis but I find this to be rare in adults. Most commonly there is some overlap of inflammation and fibrosis. The relative amount of each may help you decide how to advise your patient since there is no definitive plan that works optimally for all.
The role of food allergy in adult EoE is also variable but there are data on utilizing a 6 or 8 food elimination diet improving some subjects (1,2,3). It is controversial if IgE skin testing or patch testing is preferable to the 6 or 8 food elimination diet. However, the 6 or 8 food elimination diet is very challenging and affects quality of life. Endoscopy with biopsy would be necessary to determine if the diet is affecting the disease as symptoms are often delayed. After foods are reintroduced then repeat endoscopy is necessary to determine if the eosinophils have increased. I have been disappointed with utilization of swallowed corticosteroids in the disease. The role of biologics affecting eosinophils is of great interest but these expensive treatments are not approved for EoE (6).
I would discuss with your patient that there may be benefit in reducing exposure to foods to which he/she is allergic or possibly reducing inhaled allergen sensitivity if there is any suggestion of association with exposure to inhaled allergen and symptoms. If your patient is seeking a preventative strategy, then I would consider either the diet or inhalant immunotherapy or both (5). However, if primarily fibrotic histology, I would probably recommend periodic dilation. The latter may be beneficial for up to 10 years. If the requirement for dilation becomes more frequent, I would re-explore the diet and or inhalant immunotherapy.
1. Liacouras CA, et al. Eosinophilic esophagitis: Updated consensus recommendation for children and adults. J Allergy Clin Immunol 2011 (July); 128(1):3-20.
2. Lucendo, Alfredo J., et al. "Empiric 6-food elimination diet induced and maintained prolonged remission in patients with adult eosinophilic esophagitis: a prospective study on the food cause of the disease." Journal of Allergy and Clinical Immunology 131.3 (2013): 797-804.
3. Gonsalves, Nirmala, et al. "Elimination diet effectively treats eosinophilic esophagitis in adults; food reintroduction identifies causative factors." Gastroenterology 142.7 (2012): 1451-1459.
4. Simon, Dagmar, et al. "Eosinophilic esophagitis is frequently associated with IgE-mediated allergic airway diseases." Journal of allergy and clinical immunology 115.5 (2005): 1090-1092.
5. Konikoff, Michael R., et al. "A randomized, double-blind, placebo-controlled trial of fluticasone propionate for pediatric eosinophilic esophagitis." Gastroenterology 131.5 (2006): 1381-1391.
6. Corren, Jonathan. "Inhibition of interleukin-5 for the treatment of eosinophilic diseases." Discovery medicine 13.71 (2012): 305-312.
All my best.
Dennis K. Ledford, MD, FAAAAI